Dvgyb 11

Application No.

GOVERNMENT OF KERALA
DIRECTORATE OF HIGHER SECONDARY EDUCATION
APPLICATION FOR ADMISSION TO THE HIGHER SECONDARY COURSE (2016-2017)
Note:-

Applicants are requested to read the prospectus and instructions carefully before filling up the
application form. Furnishing false information, if any, will be a disqualification for admission.

1. Code & Name of Qualifying Examination

2. Register Number

3. Month and Year of Passing

4. a) Code and Name of School in which the applicant

studied for SSLC or equivalent examination
:
b) Whether passed in Board Examination

..

(Tick the relevant column)

Yes

No

5. . a) Name of Applicant (in Block Letters.

Initials after the name )

b) Aadhaar Number

6. Gender (Tick the relevant column)

Female

Male

7. Category Name & Code

8. Caste and Religion

9. Date of Birth

10 a). Name of Mother

: .

Day

Month

Year

b) Name of Father

...

c) Name of Guardian

...

ACKNOWLEDGEMENT

District :
Application No.

Received the application from . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .with Application No . . . . . . . . . ...
Place:
Date:

(SCHOOL SEAL)

Name and Signature of the Principal

11. Whether the applicant belongs to OEC

(Tick the relevant column)

Yes

No

12. Whether the applicant belongs to Linguistic Minority:

(Tick the relevant column)
13. a) Whether the applicant is Differently
Abled (Tick the relevant column)
:
b) Write the Reference Number in the
Box (See instructions for item No. 13)

Yes

If Yes specify the

language: . . . . . . . . . . . . . . . .

No

Orthopaedically
Challeged

Blind

Mental/Brain
Diseases

Deaf

14. Place of Residence (Code & Name of Place):

State

15. Permanent Address

District

Taluk

Grama Panchayat/
Municipality/ Corporation

....
....
.. PIN :..

16. Address to which communications are to

be sent

...
..
PIN :..

Phone Number (with STD Code):

E-Mail Address (if any):. ..

17. Whether the applicant is eligible for bonus points under the following category(Attach copies of supporting
documents)
NCC/ Scouts & Guides/Swimming /Student Police Cadet as detailed in Para11

Dependent of Jawan killed in action

Dependent of Jawan in Service or Ex-Service

18. Participation in Sports (Attach copies of certificates)

State Level Participation (Write the number of items participated)
District Level (Write the number of grades won in the relevant boxes)
1

st

Place (but not participated in state level)

nd

2 Place

rd

3 Place

Participation

Participation

19. Participation in Kerala School Kalotsavam (Attach copies of certificates)

State Level Participation (Write the number of items participated)
District Level (Write the number of grades won in the relevant boxes)
A (but not participated in state level)

20. Whether qualified in the National/State Level Test for the National Talent Search
Examination (Attach copies of certificates)

Yes

No

21. (a) Details of participation in co-curricular activities (Attach copies of certificates). Write the number of grades won in
the relevant boxes.
A Grade
B Grade
C Grade
D Grade
E Grade
State Science Fair
State Social Science
Fair
State Maths Fair
State IT Fest
State Work
Experience Fair

(b) (Tick the relevant boxes)

Philately
Club
Red
Cross

Debating
Club
Social Science
Club

Oratory
Club

Literary Contribution
(Periodicals)

IT Club

Science
Club

Nature
Club

Forestry
Club

Literary Contribution
(School Magazine)
Maths
Club

Health
Club

Participation in Scouts & Guides (but not awarded Rashtrapathi Puraskar or Rajya Puraskar)

22. (a) No. of chances taken for passing the SSLC or equivalent examination :

Reg. No.
(b) If more than one chance, state the
Reg.No, Month & Year of previous
three appearances preceding the latest

Month

Year

1.

:
2.
3.

23. (a) Grades obtained for Qualifying Examination (SSLC March 2016) (Self attested Photostat copies of the SSLC to be
enclosed)
Subjects

Lang I Lang II

Eng

Hin

SS

Phy

Che

Bio

Maths

IT

Grades
(b) Grades obtained for Qualifying Examination SSLC March 2007 to March 2015 (Self attested Photostat copies of
the SSLC to be enclosed)
Subjects

Lang I Lang II

Eng

Hin

SS

Phy

Che

Bio

Maths

IT

Grades
(c) SSLC 2005, 2006 (Grading), SSLC(Old Schemes), CBSE, ICSE and other streams(Self attested Photostat
copies of certificates to be enclosed)
Sl.
No.

Subjects

Awarded
Grades /
Marks

Sl.
No.

Max.
Marks

10

11

12

Subjects

Awarded
Grades /
Marks

Max.
Marks

24. Schools and Subject combinations in the order of preference(to be filled after reading para 18 of the Prospectus,
Appendice 3,4 and 9)
Pref.
No

School Code

Pref.
No

Combination
Code

26

27

28

29

30

31

32

33

34

10

35

11

36

12

37

13

38

14

39

15

40

16

41

17

42

18

43

19

44

20

45

21

46

22

47

23

48

24

49

25

50

School Code

Combination
Code

DECLARATION
I do state that all the information furnished above is true. I know that any false information in the
application form will result in the cancellation of my candidature.

Name and Signature of Parent/Guardian

Signature of applicant

Place :
Date :

FOR OFFICE USE ONLY

Entered by .

Verified by ..